Professional identity of medical students: Proposing a Meta Static Structural Model

Introduction: The realization of professionalism and its desirable consequences, as the most important goal of medical education, primarily depends on identifying the process and mechanism of the professional identity formation, which in turn requires the accurate identification of components and structure of the concept of professional identity. Therefore, the aim of this study was to synthesize a static structural model for professional identity, based on the results of our previous research. Methods: In this study the theory or model construction methodology was used to synthesize a static structural model of professional identity formation for medical students. In this regard, the Walker and Avant method was followed through three steps: specifying focal concepts, reviewing the literature, and organizing concepts into an integrated and efficient representation. Results: In this study, based on the analysis of 9 selected conceptual models in the field of socialization and professional identity, first the key concepts of each model were extracted and then by carefully examining these concepts and determining their relationships and reviewing related texts, dimensions and components of professional identity were determined and presented in the form of a comprehensive structural static model. Conclusion: The advantage of the proposed model over the existing models is the explicit presentation of the dimensions, constructs, and sub-constructs of the concept of professional identity. In addition, this model can be used as a general pattern in all non-medical professions.


Introduction
P rofessional identity formation in medical students, as the most important goal of medical education, and the path to the realization of professionalism (1), has been the focus of researchers in this field for about two decades. In this regard, many conceptual models and frameworks have been developed, and efforts have been made to determine the nature and components of professional identity, how it is formed, and the factors influencing its formation (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16).
Although these studies have played an important role in identifying the complex concept of professional identity, and suggesting several educational interventions to facilitate its formation, professionalism, as the main expected outcome of these interventions, has not yet been revealed.
Perhaps the cause of these failures can be found in the special features of this process, which are mentioned below: • The professional identity formation is a complex and multi-layered process that requires the internalization of a wide range of values, behaviors, and perceptions that are often implicit, and formed through authentic work experiences subconsciously (17,18). • This process occurs simultaneously both at the individual level (psychological adaptation) and at the collective level (achieving acceptance and full participation in the professional community) (9), and therefore, unlike its visible external dimensions, examining and measuring the internal dimensions are not an easy task. • Personal identity is the foundation of professional identity (19), and based on the Kegan model, individuals are not the same in terms of the stages of social maturity (20); therefore, the speed and ease of professional socialization process, and identity formation will be different in peers.

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The influence of uncontrollable factors such as genetics, gender, and age on the process of socialization and the formation of professional identity (21), causes people to show different perceptions, and reactions in the face of the same experiences. • Several psychological factors affect how a professional identity develops, and it is not clear that how the desired image of professional-self in the future can affect professional identity development (17). • Perceived incompatibility between personal identity, and the stereotypical characteristics of members of the profession may weaken people's understanding of the practicality of the career path and the motivation to pursue it (22,23). Given these complexities, it is not possible to propose effective interventions without a deep and comprehensive understanding of this process. The more accurate the understanding of this process, the more effective the proposed interventions will be.
In this regard, in our previous study, we proposed an analytic definition of professional socialization (24), as a fundamental process through which the professional identity of medical students is formed.
According to this definition, professional socialization is a non-linear, continuous, interactive, personal and psychosocial process that is formed through the internalization of the specific culture of the professional community and its main outcome is the formation of professional identity (24).
In the next step, it is necessary to identify the dimensions and components of the concept of professional identity, and to propose a conceptual model for it as a basis for monitoring the development of its components during the socialization process.
Although there are several conceptual models about professional identity in the literature, each of them often deals with only one dimension of this concept and from a specific perspective.
Therefore, the purpose of the present study is designing a comprehensive static structural model for professional identity. By identifying the components and subcomponents of this concept, it is possible to follow how they evolve in the process of socialization, and as a result, opportunity to intervene and facilitate the formation of a desirable professional identity of medical students would be possible.

Methods
In this study, a theory or model construction method was used to synthesize a comprehensive static structural model for professional identity for medical students. In this regard, Walker and Avant approach to model synthesis was followed. According to Walker and Avant (25), the following three steps was used to synthesize the model: Step 1: "Specifying focal concepts to serve as anchors for the synthesized theory".
The theorist must first choose the subject to synthesize the theory, and to do this, s/he defines a focal concept and moves from the focal concept to other related concepts. In this stage of the study, the phrase "professional identity formation" was selected as a focal concept.
Step 2: "Reviewing literature to identify factors related to the focal concepts and to specify the nature of relationships": In the next step, a detailed search and review of the literature until 2017, in the main databases: EBSCO CINAHL scientific databases EBSCO CINAHL, Web of Science, Eric, Pub Med, Scopus, and Google Scholar was performed to achieve existing conceptual models and frameworks related to the focal concept of "professional identity formation".
Only articles containing a conceptual model or framework, published in English, and with free access to the entire article were included in the review, and quantitative or experimental articles were excluded. In this way, we reached 9 conceptual models which were carefully examined.
Step 3: "Organizing concepts and statements into an integrated and efficient representation of the phenomena of interest." After collecting data from different information sources, the theorist should depict the complex relationships between the concepts related to the phenomenon of interest, and organize the general pattern of relationships between them (25).
One of the mechanisms for developing a theory or theoretical framework is the collapse of several very similar concepts into a more comprehensive summary concept (25), then placing more relevant concepts in the main "blocks", and finally determining their interrelationships.
In this way, the concepts obtained from the previous steps as fragmented knowledge were integrated into a comprehensive model.  Domains of potential professional self-growth (Self-image, role concept, attitudes, values, and personality as) as outcomes of the socialization process.

Results
In the first step of the study, the concept of "professional identity formation" was selected as the focal concept of interest. While many studies have been published on professional identity formation, none of them has addressed the structure and components of this concept through a comprehensive approach. It seems necessary to identify the components and elements of professional identity as the first step to draw a detailed roadmap to monitor how these elements evolve during the process of socialization and management.
In the second step, 9 conceptual models obtained from this search were carefully examined in terms of the type and focus of the model, and the proposed results in relation to the concepts of "professional identity formation" (Table 1); then, the key concepts and components of each model in relation to "professional identity formation" were extracted ( Table 2). In the third step, similar concepts were categorized into two main dimensions: psychosocial and social. Then, by in-depth study of the concepts of each dimension and the relevant literature, during a precise intellectual inductive process, the concepts of each dimension were divided into subgroups, the more relevant concepts being organized as defined "blocks" and their interrelationships being determined (Table 3). It is worth noting that the idea for part of this division (prospective and normative subcomponents of affective realm) stemmed from Kelchtermans' proposed concepts for teacher's professional development (26). Thereupon, the comprehensive model of Psychosocial Model of professional Identity (PMPI) was developed (Figure 1).

Psychosocial Model of professional Identity (PMPI)
According to the proposed model of this study (PMPI), professional identity consists of two dimensions, psychological and social, each with several domains.

Psychological Dimension
The psychological dimension of professional identity was divided into three parts: cognitive, affective, and volitive.
Cognitive Realm: This part itself includes professional principles, values, norms, and power structure.  (27), contend that values and norms, as important components of any professional's culture, guide and control the activities and behavior of members of a professional group, and are closely related to each other. Professional values are intentionally chosen by the profession to shape the identity, principles and beliefs of the group members (28).
In professional socialization, people who enter a new profession, while having their own personal values, learn and internalize the values of the new profession through observation of role models (29).  (2) The formation of a proper professional identity depends on the integration of personal and professional values, and commitment to both of these values (11).
Another cognitive component of the professional identity is the understanding and acceptance of the hierarchical structure of power in medicine. In the socialization process, physicians learn from the very beginning of entering a medical school to respect the hierarchy of power, and avoid challenging the power and authority of senior physicians (30,31).
Affective Realm: The affective realm includes descriptive, evaluative, normative, and prospective components.
Descriptive component includes professional self-categorization, professional self-image, sense of belonging and a sense of distinction.
The social identity theory emphasizes that membership in a group leads to the strengthening of personality and the formation of a kind of personal classification. According to this theory, the distinction between in-group and out-group is the basis for the formation of social (professional) identity (32).
Self-image is probably one of the most important elements of individual identity and self-esteem (33).
Professional self-image is, in fact, a description of one's self in relation to membership in the professional community. This description is often based on the general principles governing professional behavior, as well as one's perception of how being judged by others (26).
Trough continual experiences of socialization, in particular culture of profession, and with improving students' performance in relation to patients, the sense of self-worth increases, and therefore the students' self-image gradually approaches the professional image of role models. Similarly, group behavior, in the process of professional identity formation, gradually leads to a sense of belonging to group members, and sense of distinction from people outside the group (34).
Evaluative component of affective realm which consists of two parts of professional selfconfidence, and self-esteem, refers to one's selfassessment as a professional (physician), and depends on "comparison with others", and "the judgment by others". In other words, professional self-esteem is the result of a balance between ideal and real professional self-image (26).
Normative component also includes role perception, attitude toward profession, comfort in professional team, degrees of work centrality, and job satisfaction. Role perception is, in fact, understanding the various aspects of the profession and its responsibilities (35). Research shows that people's perceptions and attitudes toward their professions can affect how they perform. The more positive these attitudes are, the more desirable and effective one's performance in the profession will be (36). Better performance facilitates professional identity formation by increasing self-confidence and will have consequences such as comfort in the professional team as well as job satisfaction (25).
Prospective component includes future job perspective, and refers to people's expectations of developing their future careers. During the clinical years, students assess their suitability for work in various specialties by imagining themselves in related roles, and set their future career goals based on their final choices (16).
Volitive Realm: According to Haggard and Lau (37), volition is the human capacity to take action on the basis of inner decision and motivation, and is, in fact, "the link between thought and action". Volitive realm of the psychological dimension of professional identity includes two main components: job motivation and desire for professional activity.
Medical education is a long and difficult process and requires high motivation (intrinsic motivation) to learn, academic achievement and professional identity development. Satisfaction with the three basic psychological needs is essential to stimulate and maintain this inner motivation: autonomy, competence, and relatedness (38).
The process of professional socialization can influence the motivation and desire to work in the medical profession.

Social Dimension
The social dimension of professional identity in this model includes the communicative, cohesive, and operative realms.
Communicative Realm: Communication behaviors are the most obvious means by which the physician's identity formation can be interpreted. Through communicative practices, new members, learn professional culture, and develop, maintain, and then reproduce medical ideology (39). Both verbal and nonverbal communication and the messages that students receive through them play a role in the development of their social (professional) identity (40). Through communication, students learn the meaning of symbols, jargons, and behavioral principles of group members and gradually become professional members in that community (41).
Cohesive Realm: The cohesive realm of the social dimension of professional identity consists of the following components: entitativity, coherence, wholeness, acceptance by professional group, reciprocal trust, reciprocal commitment, and degrees of loyalty.
Entitativity explains the distinction between real groups with similar goal or behavior from groups that are the result of mere aggregation of people. In other words, entitativity is the perception of a group as a single entity, distinct from its individual members (42).
Group coherence refers to the solidarity, and power of positive interaction between members of a group (43).
In other words, coherence is a kind of mutual attraction between the members of a group, which is due to the pursuit of common needs and goals that will lead to their satisfaction (43).
Acceptance by the professional group is one of the most important components of the coherence realm, and requires learning the language and culture of the profession and acquiring and mastering common skills, which leads to developing effective communication with professional members (44). To build and maintain effective relationships between members of a professional team, it is important to have mutual trust (45). According to Cruess,Cruess,and Steinert (19) trust, and mutual respect are recognized as essential components of a community of practice, and the professional identity formation of its members.
Professional commitment is the desire to be part of a group, which is the result of work experience that meets one's needs for membership in that group. It seems that the experience of feeling comfortable in a professional role, and the sense of competence in performing tasks related to the role, are directly related to professional commitment (46).
By acquiring the professional competence, and going through the stages of socialization, students are gradually accepted into the professional community and feel comfortable among team members, thus committed to the goals and members of the profession.
Operative Realm: The last part of social dimension of professional identity consists of involvement, engagement, effective professional performance and professional behavior.
Students' conscious and semi-conscious behaviors from the beginning of their entry into the community of practice include observing the behaviors and relationships of group members, especially role models, and observing how they do things, gathering information about role expectations, and searching feedback, all influencing the formation of the social dimension of professional identity and the achievement of effective professional performance (4).
In addition to developing skills, students must learn professional behaviors that facilitate successful interaction with patients, their families, and colleagues. These behaviors reflect the student's initiative, time management skills, self-directed learning ability, and individual and organizational skills, and can be an indicator of a student's ability to perform professionally (47). During the socialization process, professional values are passed on to newcomers through socially agreed-upon professional behaviors to develop professional identity (48).

Discussion
The PMPI model presented in this study is a static structural model that depicts the structure of professional identity from both internal (psychological) and external (social) dimensions. The advantage of this model over other existing models is its comprehensive approach to the concept of professional identity.
Among the existing models in this field, some have focused on the factors influencing this process (2)(3)(4)11), some have prescribed interventions to improve it without providing conceptual bases (14), and some of these models have only examined this process from one dimension. For example, in Perez's model of professional socialization (13), the focus is only on the cognitive and psychological dimensions of professional socialization, whereas Weidman (3), and Weidman, Twale, and Stein (4) in their proposed models, deal only with the noncognitive aspects of professional socialization and the social dimension of professional identity.
Some of these models also refer to some components of the two psychological and social dimensions of professional identity but in a non-structured way. For example, in the psychological dimension, Cruess et al. (11) refer to components such as "learning the (professional) language", and "learning to live with ambiguity"; Miller (5), Cruess et al. (11), and Devenish, Clark, and Fleming (12) have proposed coping with the hierarchy of power; and Edens (2), Miller (5), Cruess et al. (11), Perez (13), and Byram (16) have mentioned values, attitudes, and professional culture all of which can be considered as cognitive components of professional identity. In another model, Byram (16) refers to the professional self-image, and sense of belonging to the profession that can be considered as descriptive components of the psychological dimension of professional identity. In addition, self-confidence in Devenish, Clark, and Fleming model (12) can be considered an evaluative component of psychological dimension of professional identity.
Although all of these models have been able to help illuminate the hidden angles of this process, it seems that in order to deeply understand the process of professional formation, the dimensions and components of the concept of professional identity must be first properly displayed.
By providing a comprehensive and in-depth view of the structure of professional identity, PMPI can be the basis for further research to draw a detailed roadmap and determine milestones in the development of each component of professional identity, as well as identify the factors influencing their development.

Conclusion
In this study, based on a comprehensive review of existing models of professional identity, and analysis of each of the nine selected models, first the dimensions of professional identity and their components were extracted and then based on them, a static structural model for professional identity was developed. One advantage of this model is demonstration of dimensions, components and structure of the concept of professional identity, which is not yet available in the relevant literature.
In addition to clarifying the concept of professional identity, this model provides an opportunity to examine how the dimensions and components of this concept evolve over time, during the process of professional socialization, a development model for the formation of professional identity, which our research team is working on. This will provide an opportunity to monitor the evolution of professional identity during the socialization process, and provide appropriate interventions to facilitate and accelerate it.

Limitations
This model is designed based on review and analysis of existing models and needs to be tested with empirical evaluations.